Maternal and Neonatal Health Impact of Obstetrical Risk Insurance Scheme

Health Policy and Planning Advance Access published October 22, 2016

Health Policy and Planning, 2016, 1–13 doi: 10.1093/heapol/czw142 Original Article

Maternal and neonatal health impact of obstetrical risk insurance scheme in Mauritania: a quasi experimental before-and-after study Aline Philibert,1,2 Marion Ravit,3 Vale´ry Ridde,4,5 Ine`s Dossa,2 Emmanuel Bonnet,6 Florent Bedecarrats7 and Alexandre Dumont3

Interdisciplinary Research Centre on Well-being, Health, Society and Environment (Cinbiose), University of Downloaded from Quebec in Montreal, Montreal, Que´bec, Canada, 2Research Institute for Development, Universite´Paris Descartes, COMUE Sorbonnes Paris Cite´, UMR MERIT, Paris, France, 3IRD, CEPED, UMR 196, Universite´ Paris Descartes— Institut de Recherche pour le De´veloppement (IRD), Paris, France, 4School of Public Health (ESPUM), University of Montreal, Montreal, Quebec, Canada, 5University of Montreal Public Health Research Institute (IRSPUM), 6

Montreal, Quebec, Canada, UMR IDEES CNRS 6266, Universite´de Normandie/IRD RESILIENCE 236, Caen, France, http://heapol.oxfordjournals.org/ 7Agence Franc¸aise de De´veloppement (AFD), Evaluation Unit, Research and Knowledge Developpement, Paris, France

Corresponding author. Aline Philibert, CINBIOSE, Universite´ du Que´bec a Montre´al, Case postale 8888, Succursale Centre-ville, Montre´al (Que´bec) H3C 3P8 Canada, e-mail: [email protected]

Accepted on 22 September 2016

Abstract A variety of health financing schemes shaped on pre-payment scheme have been implemented at Universite de Montreal on October 24, 2016 across Sub-Saharan Africa (SSA) to address the Millennium Development Goals (MDGs). In Mauritania, the Obstetric Risk Insurance package (ORI) focusing on maternal and perinatal health has been progressively implemented at the health district level since 2002. Here, our main objective was to assess the effectiveness of the ORI in increasing facility-based delivery rates, as well as increases in family planning, antenatal and postnatal care, caesarean delivery and neonatal health, from demographic and health survey data between 2002 and 2011. We also examined whether the effects of the ORI varied between strata of the population. The study was based on a quasi- experimental before-and-after design to assess the causal link between availability of ORI and increase in use of maternal health services and neonatal mortality. In combination with geographical information system, difference-in-differences and odd ratio approaches were used to address our objectives. Indicators of access to care for pregnant women and neonatal health and improved in both non-intervention and intervention groups during the study period. There was no global effect of the availability of ORI on facility-based delivery rates, nor on the use of antenatal and postnatal care services, except for qualified antenatal services. However, delivery rates in local health centres with ORI increased more rapidly than in those with no ORI, the contrary was shown for hospitals. Caesarean delivery and family planning decreased with ORI. Although late neonatal mortality rates remained low in the country, a significant decrease was seen in districts without ORI. Except for some strata of the population, ORI has not really met its objective of attracting more pregnant women towards facility-based health care.

Key words: maternal health, infant mortality, community-based health insurance, Mauritania, Sub-Saharan Africa

VC The Author 2016. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. 1 2 Health Policy and Planning, 2016, Vol. 0, No. 0

Key Messages:

• Indicators of maternal and neonatal health and access to care substantially improved in all health districts independently of the availability of the ORI. • Although there was no global effect of the availability of ORI on facility-based delivery rates, nor on the use of antenatal and postnatal care services, there was signiﬁcant evidence of increasing access to birth deliveries in nearby health centres at the expense of hospitals in the districts providing ORI. • Regardless of the availability of ORI, the education level of women strongly inﬂuences the use of maternal health services. • Neonatal mortality rates remained low and no global decrease was recorded with the availability of ORI.

Introduction Blanchet et al. 2012; Frimpong et al. 2014; Ahiadeke 2015). Although >90% of pregnant women were covered in the two coun- Arose out of the United Nations Declaration of 2000, the

tries, only 67% had facility-based deliveries in Rwanda and 57% in Downloaded from Millennium Development Goals (MDGs) have stimulated interest Ghana (Speizer et al. 2014; Twahirwa 2008; Lu et al. 2012; and encouraged funding for programs that aimed at reducing child Abrokwah et al. 2014). Finally, some results on increased antenatal mortality (MDG-4) and improving maternal health (MDG-5) care seeking and reduced out-of-pocket expenditure were inconclu- (Waage et al. 2010; Bryce et al. 2013). Among the different pro- sive given differing findings between studies (Brugiavini and Pace grams introduced, some health financial strategies have been initi- 2010; Chankova et al. 2008; Mensah et al. 2010; Singh et al. 2011;

ated in Sub-Saharan Africa (SSA) to increase access to quality and http://heapol.oxfordjournals.org/ Smith and Sulzbach 2008). responsive maternal and perinatal health care, while providing fi- In Mauritania, Obstetric Risk Insurance (ORI) progressively im- nancial protection (De Allegri and Sauerborn 2007; Ridde et al. plemented at the health district level between 2002 and 2011 was 2011; Smith and Sulzbach 2008). Indeed, large amounts and unpre- based on pre-payment scheme principles and focused on increasing dictability of costs related to maternity remains one of the major quality and access to both maternal and perinatal health care. Our barriers for seeking health care (Ensor and Ronoh 2005; Kurfi et al. paper aims to assess the effectiveness of the ORI in increasing the 2013) as they absorb a significant amount of the financial capital in use of facility-based delivery care, as well as family planning, ante- the household, sometimes generating financial catastrophic expend- natal and postnatal care, caesarean delivery, and neonatal health. iture (Arsenault et al. 2013). We also examine whether the effects of ORI vary according to Among a variety of health financing systems, many pre-payment

household wealth and women’s level of education to understand the at Universite de Montreal on October 24, 2016 scheme designs have been introduced at local and/or national level equity implications of the ORI approach. across SSA (Carrin et al. 2005; Ensor and Ronoh 2005; Smith and Sulzbach 2008). Basically, a pre-payment scheme aims at increasing health care utilization but also at providing financial risk Methods protection (Smith and Sulzbach 2008). The main difference with an insurance scheme lies in risk sharing, which is necessary in this case Public health system in Mauritania but not in the case of a pre-payment scheme. They are non-profit Located in Western Africa, Mauritania has a human development systems, based on voluntary affiliation, collective pooling of index ranking of 156 out of 186 countries in 2014 (source on UNDP resource and risk-sharing, and flat membership premiums (Carrin website). In 2013, the health expenditure represented 3.8% of the et al. 2005; Onwujekwe et al. 2009, 2010). The pre-payment GDP according to the World Bank, averaging in a health expend- scheme has been progressively incorporated into the national health iture per capita of 48.96 US$. The Maternal Mortality Ratio financing strategies of Benin, Ghana, Rwanda, Senegal and (MMR) in Mauritania was 602 per 100 000 live births in 2015 Tanzania with relative success (Smith and Sulzbach 2008; Borghi (based on World Bank data). In 2015, neonatal mortality was 36 et al. 2015). and under-five mortality of 85 (World Bank data). Following the implementation of pre-payment schemes in SSA, Mauritania’s public health system is organized in a common there has been evidence of increased utilization of pregnancy-related hierarchical pyramid: the central level, represented by the Ministry care, increased facility-based deliveries and improved financial pro- of Health; the intermediate level, made up of Regional Health tection due to reduced out-of-pocket expenditure in Guinea, Mali, Directorates («Directions Re´gionales de l’Action Sanitaire»: DRAS) Mauritania, Nigeria, Rwanda and Senegal (Adinma, Nwakoby and situated in the 13 Wilayas or regions; and the peripheral level, com- Adinma 2010; Chankova, Sulzbach and Diop 2008; Ndiaye et al. posed of 53 health districts re-grouping health centres and health 2008; Schneider and Diop 2001; Smith and Sulzbach 2008). In con- posts (Renaudin et al. 2007, 2008). In 2O13, there were 53 health trast, there are a few studies that failed to identify an effect of pre- districts distributed in 13 regions. payment schemes. For example, no significant difference in overall The public health care facilities are divided into three levels. At antenatal care services, facility-based deliveries and/or maternal the first level, health posts provide primary health care and are gen- mortality were reported among members and non-members of the erally run by nurses. These include antenatal visits, normal vaginal Nouna health district in Burkina Faso (Hounton et al. 2012). While delivery, basic neonatal care, first-line treatment of obstetric compli- both Ghana and Rwanda implemented national social health insur- cations (parenteral administration of oxytocin, anticonvulsants and ance (NHIS) respectively in 2003 and 2005 and are both character- antibiotics), monitoring of children under 5 years and family plan- ized by very good progress towards universal health coverage, the ning. At the second level of care, health centres provide essential ser- effects on maternal seeking behaviour have been partially achieved vices cited above and some laboratory tests. Some health centres (Brugiavini and Pace 2010; Mensah et al. 2010; Singh et al. 2011; have a general surgical unit and radiology. At the third level, Health Policy and Planning, 2016, Vol. 0, No. 0 3

Table 1. Distribution of outcomes in the four community-based surveys

DHS 2001 NSIMM 2003 MICS 2007 MICS 2011

Mean size of households 7.78 – 7.17 7.38 No of respondent women 7728 5211 12549 12754 Mean age of women 27.88 28.02 28.44 28.59 No of women who delivered a live-born child 1979 1267 3539 3629 in the last two years before interview Modern methods of contraception 261 (3%) – 588 (5%) 756 (6%) Antennal care: at least one visit 1378 (33%) 1262 (99%) 2545 (72%) 3070 (84%) Antenatal care by qualiﬁed staff 657 (33) 917 (72%) 2545 (72%) 3011 (83%) Antenatal care: at least four visits 347 (18%) – – 1895 (52%) Facility-based delivery 1061 (54%) – 1942 (55%) 2253 (62%) Caesarean delivery 68 (3%) – – 306 (8%) Postnatal care: at least one visit 291 (15%) – 468 (13%) 1226 (34%) Early neonatal mortality (up to 7 days) 48 (2%) 37 (3%) – 59 (2%) Late neonatal mortality (up to 28 days) 56 (3%) 45 (4%) – 71 (2%) Downloaded from Abbreviations: DHS: Demographic and Health Survey; NSIMM: National Survey on Infant Mortality and Malaria; MICS: Multiple Indicator Cluster Surveys . NSIMM in 2003 did not provide data to estimate the use of modern contraceptives, the number of antenatal visits, the place and mode of delivery and the useof postnatal care. MICS 2007 did not provide data to estimate the number of antenatal visits and neonatal outcomes. regional or national hospitals provide comprehensive emergency ob- Among the 15 participating districts and the 48 eligible health care http://heapol.oxfordjournals.org/ stetric care (EmOC), including transfusions and caesarean sections. facilities, 44 (92%) received ORI between 2008 and 2011. For the purpose of comparative analysis, 1 January, 2008 was used as an arbitrary date for ‘before’ and ‘after’ analysis in districts with no Health districts and participants ORI (non-intervention group) because that date corresponds to the The present study examined health service utilization and neonatal medium of the time period and that the majority of participating mortality, using nationally representative data from four recurring health care facilities started the ORI package after 2008 in the inter- community surveys (ICSs) carried out in Mauritania: the vention group. It should be mentioned that the available databases Demographic and Health Survey (DHS) in 2001 (MEASURE DHS); did not indicate whether the respondents subscribed to the ORI the National Survey on Infant Mortality and Malaria (NSIMM) in scheme. Accessible information for ORI implementation was limited 2003; and the Multiple Indicator Cluster Surveys (MICS) in 2007 to the district level. For analysis purposes, we assumed that a at Universite de Montreal on October 24, 2016 and 2011. In all those four surveys a two-stage cluster random sam- woman who lived in a district where the ORI was available had bet- pling was carried out. The selection was conducted among census ter access and higher probability to join the ORI scheme. districts at the first stage and among households at the second stage. Data used from the ICSs were collected in districts with or with- According to sampling methods used in the surveys, households out ORI contemporaneously using consistent methods before and were representative of the whole population in Mauritania. We uti- after the implementation was introduced. The National Office of lized data on all interviewed women aged 15–49 of each selected Statistics (NOS) monitored all information collected in those four household to describe levels of contraception use. To study neonatal databases. Common used data merging procedures were carried out outcomes and levels of healthcare services use during pregnancy, de- to adjust for differences and inconsistencies among data definition, livery and the postpartum, only women who delivered a live-born format and methods in order to make the data mutually compatible. child in the last two years before the date of the interview were re- Harmonization of data from the four household surveys allowed us tained for analysis. The time period considered for the present study to consolidate information on maternal and neonatal health for extended from July 2000 to November 2011. 10414 births between 2000 and 2011. Data collected in the 48 Complementary information for mapping (geographical infor- health care facilities were integrated into one database after merging mation system or GIS) was provided by the Spanish cooperation the four community surveys cited above. The merging of data was «La Agencia Espanola~ de Cooperacion Internacional para el done through simple recoding of data categories, aggregation of Desarrollo» or AECID, and completed by available data from the data or unit transformation. The information included use of health Open Street Map platform (OCHA HDX website). The QGis soft- services during pregnancy, labour and postpartum, as well as main ware was used for mapping spatial distribution by health district. characteristics of households, women and neonates (Table 1). Data merging was done by using SPSS statistical software (ver- Study design sion 20.0; SPSS, Inc, Chicago, IL) The present study was based on a quasi-experimental adjusted before-and-after study design (Grimshaw et al. 2000). The unit of intervention was the health district and the unit of analysis was the Intervention women or neonates. We compared the levels of health service util- The ORI, which was implemented at the health district level, tar- ization and neonatal outcomes between women who lived in a dis- geted pregnant women attending antenatal care in ORI- trict participating to the ORI and those who lived in a district with participating health care facility. The scheme is based on a flat fee no ORI. The date of the first implementation of the ORI in the dis- pre-payment. Any woman attending antenatal care is given the trict of residence was used for ‘before’ and ‘after’ analyses during choice to enrol on a voluntary basis. If she agrees, she pays a fixed the study period (2000–2011). This implementation date varied premium and automatically becomes member for all maternity- from 2002 to 2011 among districts that participated to the ORI. related care in any participating health care facility of the district 4 Health Policy and Planning, 2016, Vol. 0, No. 0 where she was enrolled. The premium can be paid in one or two in- was introduced). Based on an average of 145 women per district stalments and varies from 5500 ouguiyas (14 euros) in districts out- who delivered in the past two years before the date of the interview, side of the capital Nouakchott to 6500 ouguiyas (16 euros/18 USD) an observed intra-cluster correlation coefficient (q) of 0.30, and an in Nouakchott. This remained lower than in other public maternities alpha error of 0.05, the minimum number of women required per where a delivery cost varies between 11 and 30 euros/12 and 34 group to reach 80% statistical power was 1245 (Software ACluster- USD for a caesarean-section up to 200 euros/224 USD. (Renaudin, designVR 2005, version 2.0, World Health Organization). Prual et al. 2007; Vinard 2011). We assessed the effect of the availability of the ORI in the district Maternity-related care for the ORI membership included at least: on facility-based delivery rate using multivariate generalized four antenatal visits; all prophylactic treatments; one blood test estimating-equations extension of logistic regression models to ac- (haemoglobin level, blood group and rhesus); one urine test (pro- count for the clustering of women within districts. Changes in the teinuria, glycosuria) at each antenatal visit; one ultrasound scan dur- odds of facility-based delivery in the two groups between ‘before’ ing the first trimester; treatment for any pathologies related to period and ‘after’ period were compared with the use of an adjusted pregnancy and delivery, skilled delivery and emergency obstetrical odds ratio (with 95% confidence interval) for the interaction be- care (EmoC) if needed, including caesarean section; ambulance tween group (district with ORI vs district with no ORI) and time transportation to a higher level of health care; hospital care if trans- period (before vs after). The difference in rate changes between ferred; and one postnatal visit (Renaudin et al. 2007, 2008). the two groups and the adjusted odds ratios for interaction meas-

The ORI was firstly implemented in 2002 in two health districts ured the intervention effect with the difference-in-difference ap- Downloaded from of Nouakchott (Sebkha and El Mina) and since then, has extended proach, which was adapted to multivariate hierarchical analyses of still further in other districts outside of the capital. At the end of clustered binary outcomes (Card and Krueger 1994). Two-tailed 2014, the ORI was available in 144 out of 627 public health care P values of less than 0.05 were considered to indicate statistical facilities (93/528 posts, 40/81 health centres and 11/18 hospitals). significance. The selection of participating health care facilities was based on a All primary analyses include adjustments for pre-specified factors http://heapol.oxfordjournals.org/ series of conditions, such as estimation of the needs in the area and that could modify the effect of the intervention. These included ad- rate attendance at the facility in the targeted districts (Renaudin justments for district localization (Nouakchott vs other region), level et al. 2007, 2008). The implementation of the ORI was supposed to of the ORI adhesion (ratio of the adhesion to the expected birth be accompanied by an important step in improving the quality of deliveries) in the targeted district (<50, 50–79 and 80% and more), care and in raising the awareness of the population of the district be- rural versus urban context, highest level of health facility in the dis- fore the ‘opening’, a technical support regarding supervision of med- trict of woman’s residence (post, centre or hospital), highest level of ical staff and by the existence of a health insurance manager. health facility in the municipality of woman’s residence (post, centre In parallel, drugs, supplies and essential equipment for appropri- or hospital), household size, household wealth category (quintiles), ate obstetric care are provided to participating health care facilities woman education level (none, Koranic education, primary, second- before starting implementation (Renaudin et al. 2007). The bene- ary level and more), marital status (married vs non married), mater- at Universite de Montreal on October 24, 2016 fits generated by the enrolment fees help to operate the health nal age categories (<18, 18–35 et 35þ years), parity and multiple care facilities. Those include essential drugs and supplies and incen- pregnancy (Y/N). Household economic status or wealth index was tives paid to health workers (Renaudin et al. 2007, 2008); the estimated on the value of the selected household’s asset ownership, fixed salary of health workers being ensured by the government such as commodities purchased in the markets (household assets, e.g. and new equipment by the government or donors. In general means of transportation, possession of a television, phone), house- the ORI starts in concomitance in the health facility with the hold size and housing characteristics. The wealth index of house- highest level of care facility (e.g. the referral hospital), and some holds was considered as a composite measure of living standards. We with lower level of care (e.g. heath post or center) in the participat- collected data on household ownership of selected assets and used ing districts. principal components analyses to generate household asset-based proxy wealth indices, as commonly described in other studies (Vyas and Kumaranayake 2006; Howe et al. 2008; Gunnsteinsson et al. Outcomes 2010). The wealth index was divided into quintiles for better dis- The primary outcome was the facility-based delivery rate. All deliv- crimination (from the lowest Q1 to the highest quintile Q5). eries occurring in a health care facility were considered as facility- To assess whether the intervention effect varied between based. Public health care facilities include hospitals, district health subgroups of the population as household wealth and/or woman center and health post. education level, we tested the corresponding three-way interactions: Secondary outcomes included population-based rates of current subgroup x intervention x time. Subgroup specific intervention use of modern contraceptives, antenatal and postnatal care attend- effects were reported for outcomes with significant three-way inter- ance, caesarean delivery and neonatal mortality. We considered actions (tests were two-tailed, with P < 0.05 considered to indicate three indicators for antenatal care attendance: (i) at least one visit, statistical significance). (ii) at least one visit with trained medical staff and (iii) four visits or Pre-specified secondary outcomes were analysed by means of more during pregnancy. Two time periods were considered for neo- methods similar to those used for the primary outcome. Analyses of natal mortality: early (0–6 days of age) and late neonatal mortality contraceptive use were based on all women age 15–49; analyses of (7–27 days of age). health service use during pregnancy, labour and post-partum were restricted to women who delivered a live-born child in the last two Statistical analyses years before the date of the interview; analyses on neonatal mortal- The sample size was calculated in such a way to maximize statistical ity were restricted to live-born child. power, while demonstrating a significant difference in facility-based All analyses were performed with the use of Stata 12 software delivery rate of 30% between the non-intervention and intervention (StataCorp. 2009. Stata Statistical Software: Release 11.0. College group (expecting rate of 80% - average rate of 50% before the ORI Station, TX: Stata Corporation). Health Policy and Planning, 2016, Vol. 0, No. 0 5 Downloaded from http://heapol.oxfordjournals.org/

Figure 1. Distribution of the health districts that participated to the Obstetrical Risk Insurance (ORI) scheme before and after 2008.

Results between household wealth quintiles, the effects were not significant. at Universite de Montreal on October 24, 2016 However, facility-based delivery rates significantly increased more Figure 1 illustrates the heterogeneous distribution of health districts rapidly for educated women living in districts with no ORI as com- participating to the ORI scheme before and after January 2008. The pared with those living in districts with ORI (OR ¼ 0.54; 95% implementation of the ORI was restricted to Nouakchott and the CI ¼ 0.33–0.89; P ¼ 0.038). southern part of the country. It started in Nouakchott (2002) and Furthermore, the availability of the ORI had no positive signifi- then was expanded to other districts in the southern regions from cant effect on antenatal and postnatal care attendance after adjust- 2005. Table 2 shows the level of enrolments per district (mean pro- ing on covariates (Table 5). Only qualified antenatal care increased portion of pregnant women who paid a fixed premium between with ORI (OR ¼ 1.53; 95% CI ¼ 1.12–2.06; P ¼ 0.008). In contrast, 2008 and 2010) and Figure 2 illustrates the distribution of the pro- rates of caesarean delivery and modern contraceptives significantly portion of enrolment for the Districts that participated to the ORI. increased more rapidly in districts with no ORI (for caesarean deliv- Among the 15 districts where the ORI was implemented, the mean ery: OR ¼ 0.42; 95% CI ¼ 0.22–0.78; P ¼ 0.006 and for modern adhesion rate in the district reached 81.5% but this rate was <80% contraceptive use: OR ¼ 0.42; 95% CI ¼ 0.27–0.68; P < 0.001). The *ranging from 35 to 70%) in seven districts. effects on secondary outcomes related to maternal health service use Table 3 shows the characteristics of pregnant women by non- were significantly different between educated and non-educated intervention and intervention groups before and after the implemen- women or related to the household wealth. There was a significant tation of the ORI. We observed that before and after introduction of increase in qualified ANC for wealthiest women and a diminution the ORI, women of the intervention group (district with ORI) were of early neonatal death in the poorest and non-educated women likely to live in Nouakchott, in the western part of the country, or in having no access to ORI (see Appendix 1). The increase of caesarean an urban setting. It also arose from Table 3 that those women had section was lower after ORI implementation in wealthy women. better access to high level health facilities (hospital), and were As shown in Table 5, availability of the ORI scheme in the dis- slightly better educated and less poor. trict of residence did not decrease early or late neonatal mortality As shown in Table 4, there was no global effect of the availabil- rates. On the contrary, late neonatal mortality rates globally ity of the ORI on facility-based delivery rates. While rates increased decreased more rapidly in districts with no ORI as compared with in both non-intervention and intervention groups, no significant dif- districts with ORI (OR ¼ 2.13; 95% CI ¼ 1.00–4.54; P ¼ 0.049). ference was observed between them after adjusting on covariates. However, the number of deliveries in health care centres increased more rapidly in districts with ORI than in those with no ORI (adjusted OR ¼ 2.34; 95% CI ¼1.64–2.32; P < 0.05). In contrast, deliv- Discussion eries in referral hospitals increased more rapidly in districts with no Our findings arising from the merging of household health surveys ORI than in those with ORI (adjusted OR ¼ 0.33; 95% CI ¼0.23– in Mauritania prevent us to demonstrate a causal link between the 0.46; P < 0.05) where deliveries decreased. When comparing availability of the ORI and the increase in maternal healthcare 6 Health Policy and Planning, 2016, Vol. 0, No. 0

Table 2. Distribution of the level of women enrolment per health district

Region District Date of the first Mean of annual percents Level of Enrolment c(%) implementation a of enrolments b(%)

Assaba Kiffa 2005 101.23 > ¼80 Assaba Guerrou 2008 164.47 > ¼80 Brakna Aleg 2007 60.74 50-80 Brakna Boghe 2009 35.04 < ¼50 Dakhlet nouadhibou Nouadhibou 2008 43.44 < ¼50 Gorgol Kaedi 2008 84.41 > ¼80 Hodh el chargui Nema 2005 76.58 50-80 Hodh el chargui Timbedra 2009 36.04 < ¼50 Hodh el gharbi Aı¨oun 2005 87.92 > ¼80 Hodh el gharbi Kobonni 2010 40.35 < ¼50 Hodh el gharbi Tintane 2010 56.94 50-80 Nouakchott El mina 2002 94.30 > ¼80 Nouakchott Sebkha 2002 230.57 > ¼80

Nouakchott Arafat 2004 62.45 50-80 Downloaded from Nouakchott Ryad 2010 99.31 > ¼80 Total 81.52 > ¼80

aDate of the first implementation in the district is the year when the first health care facility (hospital or health center) proposed to pregnant women to enrol the obstetric risk insurance (ORI) during her first antenatal visit. b

The mean of annual percents of enrolments per district was estimated for the period between 2008 and 2010 for possible comparison. Annual percent of enrol- http://heapol.oxfordjournals.org/ ments is the total number of women who paid the ﬁxed premium during pregnancy divided by the expected number of pregnancies in the district. It is possible to have >100% for a district, which receives women from other district. cThree categories of % were generated: < 50%, 50-80% and >80%. at Universite de Montreal on October 24, 2016

Figure 2. Distribution of the level of women enrolmnent per heath district.

Note: The level of women enrolment per health district is estimated as the mean of annual percents of enrolments for the period between 2008 and 2010 for possible comparison. Annual percent of enrolments is the total number of women who paid the ﬁxed premium during pregnancy divided by the expected number of pregnancies in the Moughataa. Health Policy and Planning, 2016, Vol. 0, No. 0 7

Table 3. Characteristics of pregnant women by non-intervention and intervention groups before and after the implementation of the obstetric risk insurance

Non intervention group (no ORI) Intervention group (ORI)

Before After Before After N ¼ 3774 N ¼ 2271 N ¼ 2551 N ¼ 1818 N (%) N (%) N (%) N (%)

Health district of residence Nouakchott 364 (9.6) 176 (7.7) 564 (22.1) 603 (33.2) Zone 1 (West) 635 (16.8) 307 (13.5) 1088 (42.6) 829 (45.6) Zone 2 (South) 1987 (52.6) 1206 (53.1) 1274 (49.9) 644 (35.4) Zone 3 (North) 1150 (30.5) 758 (33.4) 189 (7.4) 345 (19.0) Missing data 2 (0.1) . . . Highest level of Health facilities in the health district of residence Post 42 (1.1) 28 (1.2) 0 (0.0) 0 (0.0) Centre 2201 (58.3) 1282 (56.5) 1565 (61.3) 976 (53.7)

Hospital 1529 (40.5) 961 (42.3) 986 (38.7) 842 (46.3) Downloaded from Missing data 2 (0.1) 0 . . . Highest level of Health facilities in the municipality of residence Post 1974 (52.3) 1282 (56.5) 964 (37.8) 694 (38.2) Centre 725 (19.2) 450 (19.8) 745 (29.2) 540 (29.7) Hospital 985 (26.1) 518 (22.8) 839 (32.9) 545 (30.0)

Missing data 90 (2.4) 21 (0.9%) 3 (0.1) 39 (2.1) http://heapol.oxfordjournals.org/ Rural versus urban settings Rural 2389 (63.3) 1620 (71.3) 1093 (42.8) 742 (40.8) Urban 1384 (36.7) 650 (28.6) 1458 (57.2) 1076 (59.2) Missing data 1 (0.0) 1 (0.0) . . Wealth quintiles of households Q1 1884 (49.9) 960 (42.3) 1048 (41.1) 586 (32.2) Q2 809 (21.4) 554 (24.4) 509 (20.0) 311 (17.1) Q3 322 (8.5) 160 (7.0) 284 (11.1) 171 (9.4) Q4 90 (2.4) 100 (4.4) 135 (5.3) 163 (9.0) Q5 625 (16.6) 486 (21.4) 544 (21.3) 585 (32.2) Missing data 44 (1.2) 11 (0.5) 31 (1.2) 2 (0.1) at Universite de Montreal on October 24, 2016 Maternal age Mean age (S.D.) 29 (69) 29 (610) 29 (69) 28 (69) Age categories <18?yr 123 (3.3) 92 (4.1) 93 (3.6) 80 (4.4) 18?34 year 2800 (74.2) 1623 (71.5) 1856 (72.8) 1362 (74.9) 35 year and more 851 (22.5) 556 (24.5) 602 (23.6) 376 (20.7) Missing data – – – – Mean parity (S.D.) 4 (63) 4 (63) 4 (63) 4 (63) Highest education level None 1194 (31.6) 553 (24.4) 726 (28.5) 427 (23.5) Koranic 975 (25.8) 542 (23.9) 680 (26.7) 363 (20.0) Primary 1120 (29.7) 802 (35.3) 797 (31.2) 689 (37.9) Secondary + 475 (12.6) 374 (16.5) 345 (13.5) 337 (18.5) Missing data 10 (0.3) – 3 (0.1) 2 (0.1) Marital status Married 3438 (91.1) 2094 (92.2) 2295 (90.0) 1648 (90.6) Not married 336 (8.9) 177 (7.8) 256 170 (9.4) Missing data – – – – Multiple pregnancy 26 (0.7) 37 (1.6) 30 (1.2) 30 (1.7) Missing data 2089 (55.4) – 923 (36.2) 527 (29.0)

Foot notes: * Women who delivered a live-born child in the last two years before interview (n ¼ 10.261). Abbreviations: ORI: obstetrical Risk insurance.

services utilization or the decrease in neonatal mortality observed in health centre versus its decrease in regional hospitals to the avail- the study time period. This was found in Renaudin et al in 2007 and ability of the ORI. This could be explained by the fact that women 2008 and in Vinard 2011 studies, but these authors failed to control may prefer to deliver where they received their ANC and other for concurrent augmentation on health service utilization, reflecting examinations offered by the ORI (laboratory and echography) be- secular trends in the country. Although most indicators of health cause they are more familiar with the health facility and the health care use were not significantly modified by the ORI intervention, we workers. Surprisingly, caesarean delivery rates and use of modern may attribute the increase in birth deliveries of proximity in local contraceptives increased more rapidly in districts where the ORI 8

Table 4. Rates of facility-based delivery.

Non interventiongroup (no ORI) Intervention group (ORI) Effect of the availability of the ORI

Before After Diff. Before After Diff. Adjusted absolute risk Adjusted Odds difference(95% CI) a Ratios (95% CI) b

number (%) % number (%) % All pregnant women Total No. 2968 2250 2031 1758 Facility-based delivery. No. (%) 1389 (46.8) 1267 (56.3) 9.5 1233 (60.7) 1286 (73.2) 12.4 0.04 [-0.09; 0.13] 0.86 [0.63; 1.21] in health post 187 (6.3) 147 (6.5) 0.2 144 (7.1) 126 (7.2) 0.1 0.06 [0.02; 0.09] 1.61 (0.90-2.91) in health center 451 (15.2) 452 (20.1) 4.9 490 (24.1) 510 (29.0) 4.9 0.14 (0.06; 0.22) 2.34 (1.64-2.32)* in referral hospital 650 (21.9) 625 (27.8) 5.9 541 (26.6) 600 (34.1) 7.5 0.22 (-0.32;-0.11) 0.33 (0.23; 0.46)* Women by level of education Non educated Total No. 1696 1083 1120 766 Facility-based delivery. No. (%) 572 (33.7) 465 (42.9) 9.2 510 (45.5) 475 (62.0) 16.5 0.10 [-0.03; -0.07] 1.18 [0.79; 01.80] Educated Total No. 1262 1167 908 990 Facility-based delivery. No. (%) 812 (64.3) 802 (68.7) 4.4 721 (79.4) 810 (81.8) 2.4 0.03 [-0.23;-0.85] 0.54 [0.33; 0.89]* Women by wealth quintiles of households Q1 Total No. 1476 955 857 585 Facility-based delivery. No. (%) 388 (26.3) 316 (33.1) 6.8 273 (31.9) 259 (44.3) 12.4 0.10 [0.05; 0.16]* 1.41 [0.88; 2.23] Q5

Total No. 246 237 211 248 Planning and Policy Health Facility-based delivery. No. (%) 213 (86.5) 204 (86.2) 0.3 194 (92.1) 231 (93.2) 1.1 0.10 [-0.17; -0.03]* 0.52 [0.21; 1.30]

Abbreviations: ORI: Obstetric risk insurance; No: number; Diff: difference. aThe adjusted absolute risk difference represents adjusted differences between group-specific changes over time and was estimated with the use of generalized linear model. bThe adjusted odds ratios for the interaction between groups (intervention vs. non intervention) and time (before vs after the implementation of the ORI) were estimated with the use of the multivariate generalized estimating-equations extension of logistic regression models. *P < 0.05 were considered to indicate statistical significance. Subgroup-specific effects were reported when a significant interaction with a subgroup variable was detected. p value of the three-way interaction for level of education*time*intervention was 0.034.

06 o.0 o 0 No. 0, Vol. 2016, ,

Downloaded from from Downloaded http://heapol.oxfordjournals.org/ at Universite de Montreal on October 24, 2016 24, October on Montreal de Universite at Health Policy and Planning, 2016, Vol. 0, No. 0 9

Table 5. Rates of health services utilization and neonatal mortality.

Non intervention group Intervention group Effect of the availability of the ORI

Before After Diff. Before After Diff. Adjusted absolute risk Adjusted Odds difference (95% CI) a Ratios (95% CI)b Number (%) Number (%)

Antenatal care attendance One antenatal visita at least (ANC1) Total no. 3684 2250 2547 1779 ANC1. no. (%) 2782 (75.5) 1867 (82.9) 7.5 1967 (77.2) 1520 (85.4) 8.2 0.05 [-011; 0.01] 0.94 [0.68; 1.31] Four antenatal visits at least (ANC4) Total no. 908 2250 1110 1270 ANC4. no. (%) 134 (14.8) 1145 (50.9) 36.1 225 (20.3) 712 (56.1) 35.8 0.00 [-0.05; 0.05] 0.78 [0.58; 1.05] Antenatal visit with qualiﬁed staff (ANQ) Total no. 3684 2250 2548 1779 ANQ. no. (%) 2293 (62.4) 1828 (81.2) 19.2 1412 (55.4) 1500 (84.3) 28.8 0.06 [0.01; 0.11] 1.53 [1.12; 2.10]*

Caesarean delivery (CD) Downloaded from Total no. 3684 2250 2546 1779 CD. no. (%) 18 (0.49) 184 (8.2) 7.7 50 (1.9) 114 (6.4) 4.4 0.02 [-0.04; 0.01] 0.42 [0.22;0.78]* Postnatal care attendance (PNC) Total no. 2924 2250 2020 1746 PNC. no. (%) 334 (11.4) 755 (33.6) 22.1 325 (16.1) 539 (30.9) 14.8 0.01 [-0.07; 0.05] 1.00 [0.73; 1.36]

Family planning (FP). use of modern contraceptives http://heapol.oxfordjournals.org/ Total no. 11348 7799 7009 6875 FP. no. (%) 389 (3.4) 417 (5.4) 1.9 355 (5.1) 444 (6.5) 1.4 0.04 [-0.06; 0.02] 0.42 [0.26; 0.68]* Neonatal mortality Early death up to 7 days Total no. 1624 2250 1626 1291 Early deaths. no. (%) 49 (3.0) 38 (1.7) 1.3 35 (2.2) 20 (1.6) 0.6 0.01 [0.00; 0.02] 1.67 [0.74; 3.80] Late death up to 28 days Total no. 1624 2250 1626 1291 Late deaths. no. (%) 60 (3.7) 43 (1.9) 1.8 40 (2.5) 26 (2.0) 0.45 0.02 [0.01; 0.03] 2.13 [1.00; 4.54]*

Abbreviations: ORI: Obsteric risk insurance, Diff: difference. at Universite de Montreal on October 24, 2016 aThe adjusted absolute risk difference represents adjusted differences between group-speciﬁc changes over time and was with the use of generalized linear model. bThe adjusted odds ratios for the interaction between groups (intervention vs. non intervention) and time (before vs after the implementation of the ORI) were estimated with the use of the multivariate generalized estimating-equations extension of logistic regression models. *P values of less than 0.05 were considered to indicate statistical signiﬁcance. was not available compared with those with ORI where standards concurrent interventions that could have interfered with the impact of medical practice may be more controlled. of the ORI. For example, from 2004 to 2007 the ACCESS/West Until now, no quantitative study has been carried out to evaluate Africa program aimed at supporting best practices in maternal and with rigorous methods the long-term impact of the ORI at the com- newborn health in Mauritania. This program was able to train doc- munity level. Vinard (2011) observed an increase in deliveries in tors to strengthen capacity in obstetric surgery, including caesarean health care facilities in one moughataa. Data from intermittent com- sections. The ACCESS program also supported the revision and munity surveys (ICSs), here from DHS, EMIP and NSIMM, were pre-testing of new norms, policies and training materials in emer- useful to assess a global impact of the availability of the ORI scheme gency obstetric and newborn care. In 2008 UNFPA, the Spanish as well as a specific impact in some vulnerable strata of the popula- Agency for International Cooperation, WHO and UNICEF initi- tion. The representativeness of these data and the large sample of ated a policy to face the lack of obstetric and gynaecology special- women in both groups and study periods is one strength of our ists in regions outside of Nouakchott. Some doctors were sent study. Indeed, the sample size was also big enough for comparative abroad for training and some foreign doctors were, recruited to analyses to evaluate a shift from 50 to 80% of facility-based practice in Mauritania. A National Health Service map has been deliveries. then introduced, reinforcing of national, regional and peripheral That ‘non causal’ relationship is probably linked to concurrent health facilities for procurement and managements of drugs at all co-interventions that were carried out nationwide between 2000 levels of the health pyramid. and 2011 and may hide the own effect of the ORI package that has Some socio-demographic changes in Mauritania after 2002 may covered so far a limited number of health facilities. Indeed, during also explain the overall rise in maternal health service utilization. this time period a series of national and international actions took The shift from a nomadic to a semi-nomadic or sedentary lifestyle place to reinforce the quantity and quality of human resources, coupled with a rural to urban migration in a great part of the broaden geographical distribution of medical staff and health facili- Mauritanian population have probably resulted into a change in ties, lead construction or rehabilitation and equipment of struc- health-seeking behaviour and an increase in health-care service util- tures, and contribute to enhance availability and access of obstetric ization nationwide (Okeibunor et al. 2013; Lindstrom and Munoz-~ care in health facilities. Appendix 2 presents a list of some Franco 2006). 10 Health Policy and Planning, 2016, Vol. 0, No. 0

The dramatic increase we observed in caesarean section rates resourced health care system in Mauritania contribute to delay in ac- (from 0.49 to 8.18%) in the districts with no ORI between 2002 cessing medical facilities. Using qualitative study will fill a gap in and 2010 is quite surprising. Even though the co-interventions cited understanding the perception of the ORI scheme and the reasons for above could partly explain that increase by greater training and/or the enrolment among pregnant women in Mauritania (De Allegri decentralization of doctors trained in surgery nationwide during and Sauerborn 2007; Ridde et al. 2014). Further research is needed that time period. The fact remains that this increase was very im- to assess the impact of the ORI scheme in terms of reduction of out- portant (þ 8%) and limited to districts with no ORI scheme. of-pocket expenditure and quality of care. Although we do not have qualitative data to support our hypotheses yet, we suggest that in districts where the ORI was available, that the scheme may have contributed to rationalize the indication for a Conclusion caesarean delivery. Indeed the health facilities offering the ORI have the obligation to monitor and report on a regular basis any informa- In general, the availability of the ORI scheme did not cause the ex- tion concerning women’s pregnancy, birth delivery and obstetrical pected increase in facility-based deliveries. No significant associ- practices. Moreover, the ORI entails management, evaluation and ation between the implementation of the ORI scheme and increased surveillance of the medical staff. The fact that any activity must be utilization of maternal health services was detected, except for deliv- cautiously reported and caesarean interventions are covered by the ery in local health care centres and qualified ANCs. In addition, the insurance when medically necessary only, it may prevent from the ORI scheme was not found to have a significant positive effect on Downloaded from overuse of caesarean interventions in low-risk women. Although a neonatal mortality. The availability of the ORI has not fully met its rate of 8.18% in districts without ORI remains in the safe and opti- objective of attracting all pregnant women towards better access to mal range 10% suggested by WHO, caesarean delivery rates dra- facility-based health care and it seems that some strata of women matically increased among women living in Nouakchott (from 0.5% benefitted more than others. To better understand and complement to 26.1%) or in household with the richest quintile (0.8–17.9%). our findings, a qualitative study that will explore the context and http://heapol.oxfordjournals.org/ This spectacular trend in the districts with no ORI let us to suggest complexity of intervention implementation and how socio-cultural that unnecessary caesarean deliveries could occur without regular dynamics influence health-related behaviours, including the decision monitoring of practices. to enrol in the ORI scheme, will be of great importance. Our study has got several limitations however. Firstly, we were not able to know whether the respondent women subscribed to the ORI scheme. Accessible information was limited to the district level, Acknowledgement i.e. the date the ORI was implemented and annual adhesion rate We thank the French Agency for Development (AFD) that has been funded among the expected pregnant women. We assumed that a woman the ORI scheme as well as the present evaluation. We also thank the Ministry who lived in a district where the ORI was available had a better ac- of Health in Mauritania. Thanks to the National Office of Statistics (NOS) cess to join the ORI scheme. However, the level of adhesion reached for providing all databases. The authors extend their thanks to the health at Universite de Montreal on October 24, 2016 80% and more in only eight out of 15 participating districts. To re- workers involved in this study (health agents midwives, nurses and doctors), mediate to that different level of women exposure to the ORI, we as well as the ORI partners in Mauritania (Direction Regionale des Affaires adjusted our models on the mean percent of adhesion per district of Sociales (DRAS), Programme National de la Sante´ Reproductive (PNSR), Syste`me National d’Information Sanitaire (SNIS), the Ministry of Health and residence. Furthermore, there could be a contamination of the non- Regional Health Directorates, and the National Office of Statistics (NOS) and intervention group, which could lead us to underestimate the real ef- National Information System (NIS), as well as Medicos del Mundo and fect of the ORI. Indeed, the women living in a district without ORI Medicos Mundi). Our study would not have been possible without their tight may have joined but in the neighbouring district. Secondly, it re- collaboration. mains possible that we have underestimated the use of maternal health services. Indeed, the only pregnancies with newborns alive were taken into account from ICSs and maybe the use of health care Funding services was different among women with newborns alive as compared to those with a stillbirth. We could also question whether French Agency for Development (AFD) has been funded the ORI scheme and women with access to the ORI used more maternity services than the present evaluation. other women, resulting in higher maternal survival bias. Finally, al- Conflict of interest statement. None declared. though our analyses were adjusted on covariates, districts without or with ORI may be different in unmeasured and systematic ways. For example, the districts participating to the ORI scheme may have References been favoured compared to the others. In this case, it is very likely Abrokwah SO, Moser CM, Norton EC. 2014. The effect of social health insur- that use of health care services was higher than elsewhere. To con- ance on prenatal care: the case of Ghana. International Journal of Health trol for this bias, the use of difference-in-difference approaches ad- Care Finance and Economics 14: 385–406. justed with covariates, were applied in comparison models. 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Appendix 1. Changes in maternal health services Appendix 2. List of available concurrent utilization and neonatal mortality in non intervention strategies/interventions that took place in the country and intervention groups after implementation of the during the study time period and their hypothetical obstetrical risk insurance and by stratifying by wom- effects on increased use of maternal and perinatal serv- en’s education and wealth quintiles of household ices and decreased neonatal mortality

Non intervention group Intervention group

Before N (%) After N (%) D Before N (%) After N (%) D DID OR

m ANC p ¼ 0.090* Downloaded from Non educated 1454 (68.4) 859 (79.3) 11.0 978 (69.7) 619 (79.9) 10.2 DID: -0.07 [-0.15; 0.00] OR: 0.80 [0.53; 1.21] Educated 1321 (85.4) 1008 (86.4) 1.0 988 (86.6) 900 (89.8) 3.2 DID: 0.02 [-0.03; 0.06] OR: 1.40 [0.79; 2.47] p ¼ 0.664 Q1 1178 (63.8) 718 (76.0) 12.2 640 (61.3) 417 (71.2) 9.9 DID: -0.06 [-0.14; 0.03] OR: 0.67 [0.43; 1.08] Q5 285 (93.2) 218 (92.2) 1.0 249 (92.1) 238 (94.9) 2.8 DID: 0.00 [-0.05; 0.05] OR: 1.42 [0.49; 4.15]

ANC_qualiﬁed staff p ¼ 0.272 http://heapol.oxfordjournals.org/ Non educated 1130 (77.7) 831 (96.7) 19.0 655 (66.9) 610 (98.6) 31.6 DID: 0.04 [-0.03; 0.10] OR: 0.80 [0.53; 1.21] Educated 1156 (87.5) 997 (98.9) 11.4 756 (76.5) 889 (98.8) 22.26 DID: 0.10 [0.05; 0.15] OR: 1.90 [1.18; 3.06]** p ¼ 0.000** Q1 924 (78.4) 698 (97.2) 18.8 441 (68.9) 412 (98.8) 30.0 DID: -0.02 [-0.09; 0.05] OR: 0.69 [0.43; 1.13] Q5 258 (89.8) 217 (98.7) 8.8 193 (76.9) 238 (99.1) 22.2 DID: -0.24 [0.18; 0.30]** OR: 3.67 [1.68; 7.94]** ANC 41 p ¼ 0.720 Non educated 62 (25.3) 502 (63.8) 38.5 91 (33.1) 270 (66.1) 33.0 DID: 0.04 [-0.03; 0.10] OR: 0.88 [0.57; 1.36] Educated 72 (21.3) 643 (58.4) 37.1 134 (22.5) 442 (57.5) 34.93 DID: -0.02 [-0.04; 0.04] OR: 0.70 [0.46; 1.07] p ¼ 0.218 Q1 34 (19.5) 407 (56.7) 37.2 43 (18.4) 200 (59.5) 41.1 DID: 0.05 [0.01; 0.11] OR: 1.04 [0.57; 1.87] at Universite de Montreal on October 24, 2016 Q5 19 (27.7) 142 (67.0) 39.2 36 (41.0) 129 (66.1) 25.11 DID: -0.12[-0.62; 0.07]* OR: 0.52 [0.28; 0.95]* Caesarean section p ¼ 0.421 Non educated 7 (0.3) 48 (4.4) 4.1 24 (1.7) 25 (3.2) 1.6 DID: -0.03 [-0.04; 0.01] OR: 0.27 [0.10. 0.75]* Educated 11 (0.7) 136 (11.7) 10.9 26 (2.3) 89 (8.9) 6.6 DID: -0.02 [-0.05; 0.01] OR: 0.53 [0.23; 1.22] p ¼ 0.015* Q1 5 (0.3) 25 (2.7) 2.4 5 (0.5) 14 (2.4) (1.9) DID: 0.01 [-0.03; 0.03] OR: 0.60 [0.50; 13.57] Q5 3 (0.8) 51 (17.9) 17.1 9 (3.3) 22 (10.3) (7.0) DID: -0.10[-0.15;-0.05]*m OR: 0.25 [0.08; 0.79]* PNCs p ¼ 0.706 Non educated 140 (8.4) 331(30.6) 22.2 130(11.7) 205 (26.9) 15.2 DID: 0.01 [-0.07; 0.05] OR:1.05 [0.67; 1.66] Educated 194 (15.6) 424 (36.3) 20.7 194 (21.4) 332 (33.8) 12.3 DID: -0.01 [-0.08; 0.08] OR: 0.95 [0.62; 1.45} p ¼ 0.131 Q1 87 (6.0) 261 (27.6) 21.6 91 (10.7) 156 (26.7) 16.1 DID: 0.07 [0.01; 0.14] OR: 1.69 [0.93; 3.09]*m Q5 74 (23.7) 108 (40.7) 17.1 57 (23.8) 77 (32.0) 8.2 DID: -0.06 [-0.18; 0.06] OR: 0.71 [0.39; 1.31] Early death (0-6 d) p ¼ 0.044** Non educated 34 (3.4) 14 (1.3) 2.1 17 (1.9) 8 (1.4) 0.4 DID: 0.03[0.01; 0.04]*m OR: 3.59 [0.98; 13.2]* Educated 15 (2.4) 24 (2.1) 0.3 18 (2.5) 12 (1.7) 0.9 DID: -0.01[-0.02; 0.01] OR: 0.70 [0.22; 2.25] p ¼ 0.027* Q1 22 (2.8) 7 (1.7) 1.1 12 (2.0) 8 (2.0) 0.0 DID: 0.02[0.01; 0.04] OR: 3.52 [0.85; 14.7]*m Q5 5 (3.0) 4 (3.5) 0.6 5 (1.9) 8 (1.2) 0.7 DID: -0.02[-0.04; 0.00] OR: 0.40 [0.06; 2.50] Late death (7-28 d) p ¼ 0.174 Non educated 38 (3.8) 19 (1.8) 2.1 21 (2.3) 11 (1.9) 0.3 DID: 0.03[0.01; 0.04]* OR: 3.11 [1.00; 9.69]* Educated 22 (3.5) 19 (2.1) 1.4 19 (2.7) 15 (2.1) 0.6 DID: 0.00[-0.02; 0.02] OR: 1.21 [0.41; 3.56] p ¼ 0.06*m Q1 27 (3.4) 9 (1.0) 2.5 16 (2.5) 9 (2.1) 0.4 DID: 0.02[0.01; 0.04] OR: 3.26 [0.89; 12.0]*m Q5 7 (3.7) 4 (3.7) 0.0 5 (2.2) 1 (1.5) 0.8 DID: -0.01[-0.01; 0.01] OR: 0.63 [0.11; 3.51]

Abbreviations: DID, difference-in-differences; OR, odd ratio. atwo-way interaction: time *intervention. bP value of the three-way interaction: subgroup*time*intervention. * 0.05; ** 0.01; *** P 0.001. *mmarginal level of signiﬁcance (0.05 < m < 0.10) elhPlc n Planning and Policy Health

Date of implementation Strategy/intervention Main goal(s) Possible effect on use Possible effect 0 No. 0, Vol. 2016, , of maternal and on Neonatal perinatal services mortality

2002 Poverty reduction strategy To increase of medical staff x X Obstetrician/gynaecologist 2003 Make pregnancy safer program To improve equipment for hospitals in Nouakchott xX and Nouadhibou 2003 Ministry of Health strategy To start incentive scheme of bonus for working i xX n regions outside of Nouakchott 2004 ACCESS/West Africa program To improve best practices in maternal and newborn X health with training of medical staff 2005-2015 National Health and Social Development Policy originated from:the To enhance access and performance of the heath system: xX third poverty reduction strategy framework (CSLP3) and the • to rehabilitate or construct new health structures health-related Millennium Development Goals in • to implement a new strategic human resources Mauritania’s health sector (WHO 2004) • to improve health and nutritional status 2008 Ministry of Health strategy Guidelines for use of maternal health services x X 2008 Common initiative from The United Nation Population Fund Reinforcement medical staff x X (UNFPA), the Spanish Agency for International Cooperation (AECID), WHO and UNICEF 2009 Ministry of Health Opening of a new Public Health school x X

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